Legislature(2007 - 2008)HOUSE FINANCE 519

02/07/2007 01:30 PM FINANCE

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* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
Moved CSHB 18(HES) Out of Committee
Moved Out of Committee
Heard & Held
+ Bills Previously Heard/Scheduled TELECONFERENCED
HOUSE BILL NO. 18                                                                                                             
     An Act amending  the functions and powers  of the Alaska                                                                   
     Commission on  Postsecondary Education; and  relating to                                                                   
     the  repayment  provisions  for  medical  education  and                                                                   
     postsecondary degree program participants.                                                                                 
MICHAEL PAWLOWSKI,  STAFF, CO-CHAIR MEYER, explained  that HB                                                                   
18 is  intended to  increase the  number of  students in  the                                                                   
WWAMI program.  The WWAMI program  is Alaska's medical school                                                                   
program  and is  a partnership  between Washington,  Wyoming,                                                                   
Alaska, Montana  and Idaho  (WWAMI), in  which each  of those                                                                   
states contributes  to the Medical  School at  the University                                                                   
of Washington (UW) based on the  amount of students they have                                                                   
entering  the   program.    For   Alaska,  that   number  has                                                                   
traditionally  been  10.   The  WWAMI student  pays  in-state                                                                   
tuition at the University of Washington  and agrees to return                                                                   
to Alaska to practice medicine.                                                                                                 
Mr. Pawlowski  continued, a student  must repay a  portion of                                                                   
the  State's subsidy  if  they  do not  return  to Alaska  to                                                                   
practice medicine.  The State  forgives 20% of the obligation                                                                   
for each  year they  practice in Alaska.   The WWAMI  program                                                                   
has  been  immensely  successful and  has  received  national                                                                   
recognition  for several years.   It has  been ranked  the #1                                                                   
Family   Medical  Education   program  in   America  for   15                                                                   
consecutive years.                                                                                                              
Mr.  Pawlowski  noted  that  Alaska  needs  to  expand  WWAMI                                                                   
because  the   State  is   facing  a  significant   physician                                                                   
shortage; a shortage  which leads to more expensive  and less                                                                   
available   medical   care   throughout   Alaska.     HB   18                                                                   
accomplishes the following:                                                                                                     
   · Expanding the WWAMI program in section 1                                                                                   
   · Allowing students to serve their residency outside                                                                         
     Alaska without accumulating interest in Section 2 -                                                                        
     (There are limited opportunities to pursue residency in                                                                    
     Alaska now with only 12 slots at Providence);                                                                              
   · Envisioning 20 students entering WWAMI a year, which                                                                       
     means that eight of those would have no opportunity to                                                                     
     pursue their residency in Alaska                                                                                           
Expanding   the   WWAMI   program   was  one   of   the   key                                                                   
recommendations  in  the recently  released  report,  "Alaska                                                                   
Physician  Supply  Task  Force"   included  in  the  packets.                                                                   
Alaska already has fewer physicians  per capita than the rest                                                                   
of  the  U.S.     And  as  our  physicians   are  approaching                                                                   
retirement age, the State needs  to do everything possible to                                                                   
recruit more and  HB 18 is a first step toward  bridging that                                                                   
1:46:36 PM                                                                                                                    
Representative  Thomas  referenced  language  "sufficient  to                                                                   
accommodate  20 new  people  each year"  &  wondered if  that                                                                   
amount would  be compounded  each year.   He wanted to  be on                                                                   
record, clarifying  that would  only be  20 students  a year.                                                                   
Mr. Pawlowski acknowledged it  was not a compounding equation                                                                   
and would only be 20 new freshmen each year.                                                                                    
Representative  Gara hoped  to finely  tune the  legislation.                                                                   
He pointed out the shortage in  the State of certain types of                                                                   
doctors.  He  noted that many doctors come  to Alaska because                                                                   
they make  a lot more money.   He proposed  tying eligibility                                                                   
for participants that  are willing to go into  the fields the                                                                   
State has serious shortages.   Mr. Pawlowski thought it would                                                                   
be difficult to  adjust for a career path,  not understanding                                                                   
specifics when entering into the medical path.                                                                                  
Representative   Gara  recommended   adding  incentives   for                                                                   
specific areas  & if  those were not  met, the student  would                                                                   
not  be given  the  subsidies and  the  annual loan  payments                                                                   
would not be forgiven.                                                                                                          
1:50:41 PM                                                                                                                    
Representative Nelson  inquired why the proposed  legislation                                                                   
stopped at the  number 10, given the serious  need throughout                                                                   
the State.  Mr. Pawlowski explained  that the bill intends to                                                                   
"establish the floor", understanding  capacity issues in both                                                                   
the University  of Alaska and  the University  of Washington.                                                                   
Increasing the number could be worked out over time.                                                                            
1:52:08 PM                                                                                                                    
JOEL  GILBERTSON,  (TESTIFIED VIA  TELECONFERENCE),  REGIONAL                                                                   
DIRECTOR, STRATEGIC DEVLEOPMENT  & ADMINISTRATION, PROVIDENCE                                                                   
HOSPITAL,  ANCHORAGE, discussed  that the physician  shortage                                                                   
in  the State  of Alaska  at this  time is  a serious  public                                                                   
health  threat.    There  is  a  physician  shortage  in  all                                                                   
specialty types  making for fragmented and reduced  access to                                                                   
care.  In the  Anchorage market place, there are  a number of                                                                   
seniors unable to receive basic primary care services.                                                                          
Mr. Gilbertson  recommended increasing the WWAMI  class size,                                                                   
a  move that  Providence  Hospital  strongly  supports.   The                                                                   
WWAMI  program   has  been  a  key  element   for  retention.                                                                   
Approximately  85% of  the  students graduating  through  the                                                                   
program  have  remained in  Alaska.   Those  individuals  are                                                                   
involved in core services of the  State.  It has been a great                                                                   
investment.  He acknowledged that  the problem is still acute                                                                   
Representative  Crawford  commented  on  concerns  voiced  by                                                                   
constituents in Anchorage that  medical access is at a crisis                                                                   
point.   He thought that the  bill would provide  a beginning                                                                   
step, however,  worried about  how to address  the short-term                                                                   
fix.   Mr. Gilbertson agreed  that there  is a need  for both                                                                   
short and  long term fixes.  The  bill would not be  the sole                                                                   
solution;  core problems  need  to be  addressed.   The  U.S.                                                                   
Congressional delegation  has taken an interest  in access to                                                                   
There are a number of efforts  in the Anchorage area that are                                                                   
happening  right  now.   One  is the  Anchorage  Neighborhood                                                                   
Health Center,  which handles many Natives coming  from rural                                                                   
communities.   The program has inadequate facilities  and can                                                                   
not meet  the volume  demand.   The clinic  is undergoing  an                                                                   
assessment through  the Denali Commission to look  at ways to                                                                   
grow  the center.    The other  large  primary care  facility                                                                   
practicing  in Anchorage  is  the Family  Medicine  Residency                                                                   
Program.    That  clinic  trains  residents,  receiving  some                                                                   
federal  support,  however,  has  been loosing  money  on  an                                                                   
annual  basis.  Most  states support  their programs  through                                                                   
direct funding  and reimbursements.   Alaska's  reimbursement                                                                   
thus far, has barely kept up with  what is happening in other                                                                   
states.   There is  interest in  strengthening the  residency                                                                   
Representative  Crawford   questioned  what  was   needed  to                                                                   
enhance the program.  Mr. Gilbertson  explained that there is                                                                   
no  one solution  to solving  the crisis.   The  Neighborhood                                                                   
Health Center  is largely  a capital  project.  That  revenue                                                                   
structure  is  stronger as  they  have  access to  cost  base                                                                   
reimbursement;  their issue is  physical space and  capacity.                                                                   
It  is a  capital project.   He  urged that  both clinics  be                                                                   
strengthened & expanded and requested further funding.                                                                          
2:01:15 PM                                                                                                                    
Representative  Gara understood that  where a person  goes to                                                                   
medical  school  has a  relationship  on  where they  end  up                                                                   
practicing, and  where the residency  program is done  has an                                                                   
even stronger  affect on where  they end up practicing.   Mr.                                                                   
Gilbertson agreed that was true.                                                                                                
Representative  Gara   noted  that  the   residency  programs                                                                   
offered in  Alaska are not as  substantial as they  could be.                                                                   
Mr. Gilbertson advised that the  residency program would like                                                                   
to expand the number  of slots available in Alaska.   Given a                                                                   
more  predictable  revenue  stream,  they would  be  able  to                                                                   
expand their  actual office  hours.   A secondary benefit  of                                                                   
more  residents coming  out  of the  program,  would be  more                                                                   
doctors feeding out into rural areas.                                                                                           
Representative  Gara  questioned  if  the  residency  program                                                                   
provided practitioners  for both  the rural and  urban areas.                                                                   
Mr. Gilbertson explained that  a good percentage have gone on                                                                   
to   work  in   rural  areas   through   the  Native   Health                                                                   
Corporations.   It helps with  the long-term training,  being                                                                   
around primary care and internal medicine.                                                                                      
Representative Gara  recommended that a quicker  solution for                                                                   
those  closer  to  practicing,   would  be  consideration  of                                                                   
expanding State support of the  residency program, especially                                                                   
in family care.                                                                                                                 
2:05:04 PM                                                                                                                    
DR. PETER  MARSHALL, (TESTIFIED  VIA TELECONFERENCE),  FAMILY                                                                   
AND GENERAL PRACTICE, CHAIR OF  WWAMI ADMISSIONS, NORTH POLE,                                                                   
referenced the  letter he submitted to the  member's packets.                                                                   
(Copy on File).                                                                                                                 
Dr. Marshall discussed  the dire need for medical  doctors in                                                                   
the bush  areas and in Fairbanks  & Anchorage.   He addressed                                                                   
the barriers that Alaska students  encounter when applying to                                                                   
other  schools.   Alaska, currently,  only has  10 spots  and                                                                   
last  year,   there  were  78   applicants.     The  students                                                                   
attempting  to  get  into the  program  apply  against  other                                                                   
states;  states   tend  to  be  "stringy"  with   the  spots,                                                                   
reserving  them  for their  own  residents.   Well  qualified                                                                   
students are  at a disadvantage  in trying to apply  to other                                                                   
medical  schools.   Doubling  the  class  size to  20,  would                                                                   
increase the ration and would help the situation.                                                                               
2:08:46 PM                                                                                                                    
Representative  Crawford  commented  that  Amendment  1,  25-                                                                   
LS0131\K.1,  Mischel,  2/06/07,   could  have  increased  the                                                                   
program number  from 20 to  30.    He was informed  there was                                                                   
not  enough physical  space  to accommodate  that  many.   He                                                                   
agreed to  not offer the  amendment at  this time.   He asked                                                                   
when the program  could be expanded.  Dr.  Marshall responded                                                                   
that he was not  equipped to answer that.   The University of                                                                   
Washington (UW) has  made a decision to increase  their class                                                                   
size  over  the next  few  years.   He  believed  eventually,                                                                   
Alaska could  have 30 students  in the program  and supported                                                                   
such a plan.                                                                                                                    
2:11:10 PM                                                                                                                    
ROD BEATTIE, PRESIDENT, ALASKA  STATE HOSPITAL & NURSING HOME                                                                   
ASSOCIATION (ASHNHA),  JUNEAU, noted  that the membership  of                                                                   
his agency  has identified the  proposed issue as  their most                                                                   
critical  concern this  legislative session.   He  referenced                                                                   
the agency handout.  (Copy on File).                                                                                            
ASHNHA  strongly  supports  passage  of  HB 18.    There  are                                                                   
approximately  seven ways to  get additional physicians  into                                                                   
   · Medical schools                                                                                                            
   · Residency programs statewide                                                                                               
   · Federal assignments                                                                                                        
   · Self selection                                                                                                             
   · Loan repayment programs                                                                                                    
   · Recruitment bonuses                                                                                                        
   · Travelers                                                                                                                  
Mr. Beattie  reiterated that HB  18 is critical  legislation.                                                                   
He pointed out that Alaska currently  suffers from a shortage                                                                   
of over  300 physicians.   The  public is  not receiving  the                                                                   
care needed.   He  urged that  the bill  move swiftly  out of                                                                   
Committee and  that the University  of Washington  is looking                                                                   
for a quick response; timing is critical.                                                                                       
2:16:14 PM                                                                                                                    
Co-Chair Meyer  questioned how soon  ASHNHA needs to  know if                                                                   
passage of the  bill could happen.  Mr. Beattie  replied that                                                                   
the deadline  to complete  the contract  negotiations  is the                                                                   
beginning of March 2007.                                                                                                        
Representative  Gara  asked  the  areas  of  the  most  acute                                                                   
shortages.    Mr.  Beattie  responded  a  lot  of  the  newer                                                                   
specialty areas and elder care,  OB's, surgeries, cardiology,                                                                   
and  internal medicine.   He  added  that targeting  students                                                                   
into specific areas would be problematic.                                                                                       
Co-Chair Meyer  asked if the State's residency  program could                                                                   
accommodate  all   20  students;  he  understood   that  only                                                                   
Providence  Hospital  offered   a  residency  program.    Mr.                                                                   
Beattie  replied  that  was correct  and  that  it  currently                                                                   
offers a 12-position residency program.                                                                                         
2:18:07 PM                                                                                                                    
DR. ROLAND GOWER, (TESTIFIED VIA  TELECONFERENCE), PRESIDENT,                                                                   
ALASKA  STATE MEDICAL  ASSOCIATION  (ASMA), GENERAL  SURGEON,                                                                   
ANCHORAGE,  provided  a copy  of  his  testimony.   (Copy  on                                                                   
Dr. Gower pointed out that ASMA  strongly supports HB 18.  He                                                                   
echoed  the  crisis  given  the  doctor  shortage  throughout                                                                   
Alaska.  There is a nationwide  shortage and recruitment will                                                                   
not get  any easier  in the  future for  Alaska.  He  thought                                                                   
that it  made sense  for Alaska  to "grow  our own  students"                                                                   
into the  field.   There are  Alaska students  that want  the                                                                   
training  but do  not have  a  school to  go to.   The  State                                                                   
providing a reasonable  payback acts as an incentive.   It is                                                                   
important  to nurture this  resource.   He offered  to answer                                                                   
questions of the Committee.                                                                                                     
Representative  Gara  inquired   how  the  legislation  would                                                                   
increase the  family residency program throughout  the State.                                                                   
Dr. Gower  explained he  was not an  expert on that  program.                                                                   
There  is a  critical  mass consideration  of  the number  of                                                                   
physicians that  can be trained  in that area.   He commented                                                                   
on specialty  training and  thought it  would be possible  to                                                                   
provide some  training to specialists  in Alaska but  many of                                                                   
that  type  training  can  not  happen  in  the  State.    He                                                                   
recommended   perhaps  creating   rotations  in  the   Alaska                                                                   
hospitals with residents from other states.                                                                                     
2:24:21 PM                                                                                                                    
PAT LUBY, (TESTIFIED VIA TELECONFERENCE),  ADVOCACY DIRECTOR,                                                                   
ALASKA  ASSOCIATION  OF RETIRED  PERSONS  (AARP),  ANCHORAGE,                                                                   
stated  that AARP  supports  HB  18.   He claimed  that  AARP                                                                   
members tend  to see physicians  more often than  the younger                                                                   
set.  Now seniors  are staying in the State  after retirement                                                                   
since  the  health services  are  improving.    HB 18  is  an                                                                   
excellent first  step in  addressing the statewide  physician                                                                   
shortage.  He urged support.                                                                                                    
2:26:12 PM                                                                                                                    
Co-Chair  Meyer   noted  that  Representative   Crawford  had                                                                   
WITHDRAWN his amendment.                                                                                                        
Co-Chair  Meyer pointed  out the  fiscal notes,  highlighting                                                                   
the new  note by  the University  of Alaska.   Representative                                                                   
Hawker noted  the number  of new  positions being added  into                                                                   
the system  and the  note associated.   He  worried that  the                                                                   
student-faculty  ratio was  excessive.   He  pointed out  the                                                                   
capital expenditure request included.   Representative Hawker                                                                   
requested a better evaluation.                                                                                                  
Co-Chair  Meyer agreed  that the  capital  request should  be                                                                   
addressed  in the Capital  Budget.   Mr. Pawlowski  clarified                                                                   
that under  the program,  until the  actual slots are  added,                                                                   
the incoming class at UAA would not be above 20 people.                                                                         
2:29:43 PM                                                                                                                    
PAT PITNEY, VICE  PRESIDENT OF PLANNING &  BUDGET, UNIVERSITY                                                                   
OF ALASKA, advised that the fiscal  note before the committee                                                                   
was precise.  There would not  be two part-time positions; of                                                                   
the $344 thousand,  approximately $44 thousand  dollars would                                                                   
be used  for staffing assistance.   It would add  to staffing                                                                   
support for the WWAMI program.   The two faculty would add to                                                                   
the  existing faculty  in  the current  program.   There  are                                                                   
seven faculty  in the  program and  approximately ½  of those                                                                   
are dedicated  for WWAMI teaching.   They are  also dedicated                                                                   
to some  biological and chemistry  teaching positions  in the                                                                   
other  departments  and research  and  service.   The  course                                                                   
curriculum in  the first  year is very  intensive.   There is                                                                   
course work  with lab and  teaching requirements; it  is more                                                                   
one-on-one.   It would be a  significantly larger load.   She                                                                   
stressed that the request to move  to 20 students will happen                                                                   
at the beginning of next school year.                                                                                           
Representative  Hawker  did  not  understand  the  merits  or                                                                   
demerits of  the ratio argument.   He was concerned  with the                                                                   
travel  component, the  contractual &  supplies.  Ms.  Pitney                                                                   
explained that those  numbers were a rough estimate  and they                                                                   
assume a modest salary.  The travel  allocation would be used                                                                   
for the entire department.                                                                                                      
Co-Chair Meyer thought the fiscal  request should be analyzed                                                                   
during a subcommittee  process.  Co Chair Chenault  agreed it                                                                   
should  be   examined  during   subcommittee  before   moving                                                                   
forward;  he  recommended  that the  capital  expenditure  be                                                                   
included in the Capital Budget  Request (CBR).  He asked that                                                                   
the fiscal note  be removed and provided to  the subcommittee                                                                   
for consideration.                                                                                                              
2:34:11 PM                                                                                                                    
Co-Chair Meyer reminded members  that the University received                                                                   
$475 thousand  dollars last year with the  understanding that                                                                   
the remainder would be allocated FY08.                                                                                          
Representative  Gara inquired  if  the bill  should pass  how                                                                   
that  would be  affecting the  capital request  process.   He                                                                   
asked  if  construction would  be  completed  by then.    Ms.                                                                   
Pitney  responded that  the $475  thousand appropriated  last                                                                   
year was being used as the planning  part of the construction                                                                   
process.   In the  event that the  bill passes, the  original                                                                   
$475  thousand dollars  allows  the planning  and the  second                                                                   
allocation in the amount of $475  thousand dollars will cover                                                                   
the  overall   construction.    Construction   completion  is                                                                   
planned for during the summer  and will be ready for incoming                                                                   
Representative Gara  asked if the capital upgrade  was really                                                                   
needed.  Ms. Pitney emphasized it was.                                                                                          
2:36:57 PM                                                                                                                    
Co Chair  Chenault  referenced comments  that the  allocation                                                                   
from last  year budget  was being  used for  planning of  the                                                                   
renovation.   Ms.  Pitney responded  that  the University  is                                                                   
preparing for  success of  the program as  the need  is high;                                                                   
the planning portion was less than $475 thousand dollars.                                                                       
Co Chair Chenault understood the  concern to get the funding.                                                                   
He worried about the funding from  last year being used.  Ms.                                                                   
Pitney replied only a small piece of that amount was used.                                                                      
2:38:50 PM                                                                                                                    
SUSANNE  TRYCK,  (TESTIFIED  VIA  TELECONFERENCE),  DIRECTOR,                                                                   
ALASKA REGIONAL  AFFAIRS, UNIVERSITY OF WASHINGTON  SCHOOL OF                                                                   
MEDICINE, explained  that the issue of the  number of faculty                                                                   
in  the  program  is  a bit  difficult  to  grasp.    At  the                                                                   
University  of  Alaska -  Anchorage  (UAA), the  numbers  for                                                                   
faculty is  lower than in  some of other  states.  It  is not                                                                   
uncommon  for a  faculty in  the second  year at  the UW,  to                                                                   
teach three or four lectures in  a semester.   There is a lot                                                                   
of time involved  in research, which makes the  teaching time                                                                   
less.  The proposed numbers are  in line with the other WWAMI                                                                   
Ms.  Tryck clarified  that they  can not  accommodate all  20                                                                   
WWAMI  students  in the  family  medicine  residency  program                                                                   
unless they only  intend to practice family  medicine.  There                                                                   
is no  direct link  in terms  of the  numbers.   It would  be                                                                   
cumbersome  to  attempt  to tie  the  shortage  of  statewide                                                                   
doctors with those  students selected for the  WWAMI program.                                                                   
The  amount of  time  it takes  to  complete  the program  is                                                                   
usually  seven years.   Ms. Tryck  urged that  the bill  pass                                                                   
from committee at this time given the deadline.                                                                                 
2:42:00 PM                                                                                                                    
Co-Chair  Meyer recommended  that  the University  of  Alaska                                                                   
fiscal note be reduced to zero.                                                                                                 
Vice Chair  Stoltze MOVED  to REPORT  CS HB  18 (HES)  out of                                                                   
Committee  with  individual  recommendations   and  with  the                                                                   
accompanying fiscal notes including  the new zero note by the                                                                   
House  Finance   Committee.    Vice  Chair   Stoltze  briefly                                                                   
Vice Chair Stoltze  noted that he supports the  initiative to                                                                   
bring more  doctors into  Alaska.  He  worried if it  had not                                                                   
been  mandated,   it   would  not  have   come  through   the                                                                   
University.  He complimented the  statewide professionals for                                                                   
making the  legislation happen  and wanted  to make  sure the                                                                   
leadership  on   the  issue  continues  to  be   the  medical                                                                   
community.  Vice Chair Stoltze WITHDREW his OBJECTION.                                                                          
There being NO further OBJECTIONS, it was so ordered.                                                                           
CS  HB 18  (HES) was  reported out  of Committee  with a  "do                                                                   
pass" recommendation  and with a  new zero note by  the House                                                                   
Finance  Committee   and  fiscal   note  #1  by   the  Alaska                                                                   
Commission on Postsecondary Education dated 1/31/07.                                                                            
AT EASE:            2:44:39 PM                                                                                                
RECONVENED:         2:50:46 PM                                                                                                

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